Background The hospital to community transition puts patients at an increased risk of having medication errors. In 2015, a discharge medication reconciliation (MR) process was implemented in the internal medicine ward. However, because discharge orders were being written at patients’ discharge, MR was completed once the patient had already left the hospital. This process made correction of discrepancies time-consuming (phone call to patient and patient’s GP). This is why in 2016, we decided, in collaboration with the internal medicine prescribers, to reorganise the discharge MR process.

Purpose Implementation and assessment of a pre-discharge MR process in an internal medicine ward.

Material and methods Discharge process from the internal medicine ward was reorganised and discharge orders were completed the day before patient’s discharge. Every morning, the pharmacist reviewed the discharge prescriptions of all the patients returning home and having received MR at admission (patients≥65 years old and/or having at least three chronic treatments). The discharge prescription was compared to the best possible medication history performed at admission and to the hospital prescription on the day of discharge in order to identify all the medication discrepancies. Discrepancies were then assessed with the prescriber to determine whether they were unintentional (UMD). UMD prevalence on discharge prescription and rate of UMD corrected were assessed and compared to the previous organisation (MR performed after patient’s discharge).

Results During 3 months, 52 patients were included. Among the 436 medications prescribed at discharge, UMD prevalence was 6.4% (30) among which 93% (28) were corrected, leading to an uncorrected and maintained UMD prevalence of 0.5% (2/436) in discharge orders. This new MR discharge organisation led to a 79.6% decrease (2.3% to 0.5%) in UMD prevalence and a 2.3-fold increase (40% to 93%) in correction rate in comparison with the previous organisation model.

Conclusion This study shows that anticipation of discharge prescriptions combined with MR is more effective in reducing UMD at discharge than a post-discharge MR. However, anticipation can sometimes be challenging in cases of numerous and/or unplanned discharge. In these cases, post-discharge MR could be performed to intercept and correct the main medication errors.

No conflict of interest